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Casings <br />Casing <br />Depth from Surface <br />Wall <br />Outside <br />Screen <br />Slot Size <br /># <br />Feet to Feet <br />Casing Type <br />Material <br />Casings Specificatons <br />Thickness <br />Diameter <br />T <br />Type <br />if any <br />Description <br />(inches) <br />(inches) <br />(inches) <br />1 <br />0 <br />105 <br />Blank <br />Other <br />N/A <br />0.218 <br />2.375 <br />Casing <br />1 <br />105 <br />200 <br />Screen <br />Other <br />N/A <br />0.218 <br />2.375 <br />Milled <br />5 <br />Slots <br />Annular Material <br />Depth from <br />Surface Fill Fill Type Details <br />Filter Pack <br />Size <br />Description <br />Feet to Feet <br />0 <br />90 Cement Portland Cement/Neat Cement <br />90 <br />1 203 Other Fill See description. <br />Coke Breeze <br />Other Observations: <br />Borehole Specifications Certification Statement <br />Depth from I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br />Surface Borehole Diameter (inches) Name GREGG DRILLING & TESTING INC <br />Feet to Feet <br />Person, Firm or Corporation <br />0 1 203 10 <br />RECEIVED <br />.JUL 0 9 20131 <br />Q1VIRONNIENTAL HEALTH <br />I)EPARTNlENT <br />2726 WALNUT AVENUE SIGNAL HILL CA 90755 <br />Address City State Zip <br />Signed electronic signature received 06/04/2018 485165 <br />C-57 Licensed Water Well Contractor Date Signed C-57 License Number <br />DWR Use Only <br />CSG # I State Well Number I Site Code Local Well Number <br />Latitude Deg/Min/Sec <br />TRS: <br />APN: <br />Longitude Deg/Min/Sec <br />Form DWR 188 rev. 12/19/2017 Page 2 of 2 <br />